Provider Demographics
NPI:1316089964
Name:JED, JERRY (OD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:JED
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 N BROADWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-2214
Mailing Address - Country:US
Mailing Address - Phone:914-946-0324
Mailing Address - Fax:914-946-2270
Practice Address - Street 1:15 N BROADWAY
Practice Address - Street 2:SUITE A
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-2214
Practice Address - Country:US
Practice Address - Phone:914-946-0324
Practice Address - Fax:914-946-2270
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003557-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
C33391Medicare ID - Type Unspecified